The Australian Government has announced that it will contract with a health service provider to manage and run an Ebola treatment facility in Sierra Leone to help control the Ebola epidemic.1 The facility, while mainly staffed by locals, will be supported by Australian volunteers. Previously Australia had provided financial aid, rather than hands-on assistance.
These Australian volunteers will face many challenges, but what of local medical practitioners faced with suspected cases of the disease? Guidelines have been issued by the Department of Health in relation to clinical responses, but there are also difficult ethical dilemmas associated with public health emergencies which do not generally arise during day-to-day clinical practice, not to mention legal issues.
Duty of Care
Whilst doctors have a duty to look after the health and well-being of their patients, they also have a duty to protect themselves, other patients, colleagues, their family and the wider public from harm.
There may be limited resources available to care for a large number of sick individuals during a public health crisis, and doctors in such situations may be required to prioritise which individuals receive treatment over others.
This was evident in the current Ebola outbreak where the first three doses of ZMapp, an experimental serum, were administered to American medical missionaries, who have recovered, and a Spanish priest, who has since died.
Their treatment was widely criticized despite the practical justification that medical workers should be treated first so they could continue to help others. Rationing scarce medical resources will always be highly controversial and an ethical dilemma for doctors. Whether a legal duty is breached may depend on whether peer professional opinion defences can be established.
Use of unregistered interventions
Possible vaccines and treatments raise another ethical question – is it ethical to offer unregistered interventions with as yet unknown efficacy and adverse effects as potential treatments or prevention?
The World Health Organisation has pronounced that it is ethical to treat Ebola patients with experimental drugs to counter the outbreak, despite the drugs not being trialled on humans and not yet being licensed by the US Food and Drug Administration. One only need recall the disastrous clinical trials of the experimental pharmaceutical drug TGN 1412, where six volunteers suffered catastrophic organ failure, to be reminded how dangerous this can be.
In Australia, doctors owe the same duty of care for clinical trials as other medical treatments. However, the standard of care widely accepted by peer professional opinion as competent professional practice for innovative medicines is more blurred.
Responsibilities of medical practitioners and ‘Quarantine Politics’
Doctors need to be alert to the possibility of Ebola by recognising its symptoms, taking a travel history, and promptly isolating and testing ill travellers who have returned from the outbreak regions in the past 21 days and have symptoms consistent with Ebola.
Ethical issues arise when suspected cases do not consent to being quarantined, as occurred recently in Maine, USA. There, a nurse retuning after providing medical assistance in Sierra Leone was ordered to be quarantined for 21 days but defied orders and went about her life in public. The dispute went before the Court, which ultimately determined that the nurse was not required to be quarantined as she did not actually exhibit any symptoms.
Whilst this issue has not yet arisen in Australia, it is a reminder of the conflict that arises between a person’s freedom and concern for public health.
The Ebola epidemic highlights the ethical and legal challenges that arise during public health emergencies. While at present the risk of a person in Australia being infected with Ebola is extremely low, Australian medical practitioners must keep in mind issues that arise with limited health resources, experimental treatments and mandatory quarantining.